The blog of Ashish Jha — physician, health policy researcher, and advocate for the notion that an ounce of data is worth a thousand pounds of opinion.

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Average care at a typical hospital on an ordinary Sunday

On a warm and sunny August Sunday, I was rollerblading with my kids on the Shining Sea Bikeway. On mile nine on the trip, I hit a tree root, went flying, and landed on my shoulder. I could tell immediately that something was wrong — I couldn’t move my arm and was in the worst pain of my life. Feeling for my left shoulder, it was obvious that I had dislocated it. What happened next was that I received some of the best care of my life – unfortunately it was not from our healthcare system.

As I was lying on the bike path, nearly everyone stopped and asked how they could help. A pediatric nephrologist offered to pop my shoulder back into place. I declined. This wonderful couple on a two-person reclining bike stopped and insisted on pedaling me to the hospital. We were far from the road and knew that calling an ambulance was not straightforward. So I sat with my left arm dangling, in excruciating pain, while David rode the bike to Falmouth Hospital. It was a 20 minute ride finishing with a very steep hill. David apologized after each bump on the road as he heard me swear and wince.

The Emergency Room:

We finally made it to the ER, and, ironically, it was then that my care stopped being so wonderful.

It started off well enough – a triage nurse saw me walking in holding my arm, in distress. She got me a wheelchair and brought me into triage. I explained what happened, gave my name, date of birth and described the pain as the worst of my life. I was then shuttled to registration, where I was asked to repeat all the same information. It felt surreal: I had moved all of 10 feet and yet somehow my information hadn’t followed me. The registration person asked me question after question. Initially, the same ones: name, address, phone #, etc. Then, my Social Security number (presumably so they could go after me if I didn’t pay my bill), my primary care physician’s name, his address, his phone #, my insurance status, my insurance #, my insurance card, my emergency contact, their address and phone #, etc. etc. etc.

I told her I was in excruciating pain and needed help. A few more questions, she said. She needed the complete registration.

I was wheeled to radiology and sat in a hallway for what felt like forever, groaning in pain. I couldn’t find a comfortable position. Six or seven people walked by – and as they heard me groan, they would look down and walk faster. The x-ray technologist avoided eye contact. It was hard — I was right outside her room. Finally, I asked a passerby if she could help. Caught by surprise (I must have sounded human), she stopped. She looked at me. She then went into the x-ray suite. A few minutes later, a second technologist came out, saw my arm, and was the first to acknowledge that my arm looked painful. He told me the ER was pretty quiet and he would get me in right away.

One of the ways we measure quality of emergency department care is to examine the proportion of patients with a fracture who receive pain medications within 60 minutes. While I don’t know who came up with 60 minutes, it wasn’t anyone with first-hand experience sitting in a waiting room in excruciating pain. Even though I did not have a fracture, my injury was comparable – and I was getting pretty close to 60 minutes when I was wheeled from the x-ray suite back out to the waiting room. I hadn’t been assigned a room, I was told. Still no pain medicine. How much longer before I could be seen, I asked? No one seemed to know. When I was eventually wheeled back to the treatment area, I was told I had to wait for a physician before I could get pain medication. How soon, I asked? No one knew. The ER doc actually came pretty quickly — he ordered some morphine and things became better. He was very good at what he did – he manipulated my shoulder and while it was insanely painful, I knew it had to be done. My shoulder popped back in quickly with amazing relief.

The Lessons Learned:

The rest of the time in the ER was uneventful. As I sat on my gurney awaiting the results of the repeat x-ray, I sent out a Tweet. I described the experience as wonderful people, awful system.

1) People who work in hospitals can be wonderful: One could ask if the people there really had been so wonderful. Why didn’t the triage nurse take me back right away and skip parts of registration (or at least express sympathy for my pain)? Why couldn’t the registration person wait for the minute details? Why did all those people look away when they heard me groan? I can’t imagine walking by somebody groaning in pain and ignoring them. Except I probably have. In the hospital. And why do we do that? Why do we leave our humanity at the door when we arrive to work? I assume we just get desensitized to suffering.

What was remarkable was that there were people who were able to break out of that trap. When I was able to engage someone as a person, they responded. The woman who stopped when I asked for help. The second x-ray technologist who expressed sympathy for my pain. The ER physician who took care of my shoulder quickly when he realized the severity of my pain. It is the job of healthcare leaders to create a culture where we retain our humanity despite the constant exposure to patients who are suffering. It’s clearly possible and several people showed it at Falmouth. And yet, too few healthcare organizations appear to have those kinds of leaders.

2) We have a lousy system. There were so many reminders in my short visit to the ER. Asking someone in excruciating pain to repeat demographic information and wait for their insurance information to come up on the computer? Even when I pleaded with her, she blew it off, reassuring me insurance information was important. Because that’s how we do business in healthcare. Making sure I was insured was much more important than making sure I was treated quickly.

When telling this story to colleagues, one person even defended it. Asking people to wait in pain is fine, she said, because registration information is valuable. Really? That’s the tradeoff? We can’t design a system where some of the information is obtained when the pain is better? There was no way to take my credit card as collateral and let me go on my way? Can we really not design a better flow so that patients with severe pain get relief without waiting needlessly? There were so many little opportunities to make my process faster, but it was clear that there was no reason for the hospital to invest in those changes. No one holds them accountable. In most industries, the payer holds the provider of poor services accountable. Not in healthcare.

Not an extraordinary story:

The biggest lesson for me was that this was not an extraordinary story at all. When I told my story to colleagues the next day, no one was surprised. We accept that when we walk into a hospital, we give up being people and become patients. We stop receiving care, the way I did on the bike path. Instead, we receive services. And when you are in pain, the difference between care and services is stark.

People in healthcare get upset when they are compared to other industries, but on this one, it’s tempting. So many companies have figured out how to do flow better. How to keep their employees engaged and sensitized and not burnt out. But in healthcare, we underinvest in that. Companies spend vast amount of time studying flow and thinking about how to ensure that customers get the services they need quickly. In healthcare, it’s considered a luxury and most organizations do very little.

Part of the reason our acceptance of mediocrity is particularly frustrating is that this is what care looks like in the most expensive system in the world. If we, as a society, chronically under-funded healthcare services, one could understand the lousy service we often provide our patients. I could live with being parked in the x-ray waiting area, ignored — if I knew that we were instead spending precious societal resources on education and research and building roads and bridges. But that’s not our story. We spend an enormous amount of money, and accept mediocre service in return.

Now that we are measuring patient experience and ER wait times as quality measures, I wondered how Falmouth hospital did. Out of curiosity, I looked up its ratings. They are fine. Average. This is not an outlier hospital. My experience was not an outlier experience. And that is the biggest disappointment of all.

When I was expecting my second child, the hospital asked me to “pre-register” by filling out a ream of paperwork. I did, expecting that this would allow me to sail right into labor & delivery.

The day arrived when I was to deliver my baby. Remember, this was my second child; I did not go running in as soon as contractions started. So I was in active labor, very uncomfortable, before I even left to go to the hospital. My husband dropped me off at the hospital entrance and went to park the car.

The lady at the front desk insisted that I couldn’t be admitted until I gave her all of my information! Name, address, insurance info…I told her that was all in their files, but she literally would not let me leave the lobby (wouldn’t even have them bring me a wheelchair to sit in–I was standing) until I went through the whole admissions rigamarole. It probably took 10-15 minutes tops, but it was a very, very painful 10-15 minutes. Worst of all, she didn’t even apologize for making me go through that. Douchebag.

Ashish, I am so sorry for what you went through. We, too, have had disappointing ER experiences. One time Ainsley was having a severe allergic reaction to egg and the staff still made us sit in the waiting room and fill out the paperwork before they would call us back to see a doctor. Dave and I avoid the ER like the plague because of the long waits and lack of communication we’ve encountered both in the waiting area and in the exam room. Whenever one of the kids gets injured, his first instinct is to say, “We are NOT going to the ER.” This is not good.

“We accept that when we walk into a hospital, we give up being people and become patients. We stop receiving care, the way I did on the bike path. Instead, we receive services. And when you are in pain, the difference between care and services is stark.”

The dichotomy between patient and person is interesting to think about. Do you believe it has anything to do with the distinction between health as a commodity or health as a human right?

I work in a pediatric facility. My specific area is oncology. Recognizing that customer services is lacking in health care, many of our departments, including my own, have gone through the LEAN training (made famous by Toyota). The ER was the first unit to be LEAN and the results were so good, our hospital bit the bullet and signed up more of our busiest outpatient clinics. My experience with LEAN in our clinic is that is really does improve flow and concentrate focus on the optimal outcome, which is the patient is served efficiently and effectively with no waste of resources or time, both the patient’s and the providers. I think the biggest barrier to preventing situations like yours is when we as providers are not being open to realizing that the way we have always done it is it not the best way of doing it. That attitude can come from hospital management and/or the staff members and providers. Opening the doors to a critical outside perspective on our processes and how they could be negatively impacting the delivery of care came for us in the form of LEAN. It is like having LEAN there gave everyone permission to say ok, we know something is wrong in what we are doing but we don’t know how to fix it. It allows for those doing the day to day work to identify all the hiccups and problems they see preventing them from delivering good care in an accepting environment with no fear of being seen as a whiner. Then once you have all the data, you break down the process and start over from scratch. It was a great experience, I think Falmouth ER should sign up! FYI….I have absolutely no connection to LEAN

Some of my recent experiences mirror yours and at the same time I had great care in some ERs. I am a physician and can fully empathize with the sentiments you expressed. I love the difference you make between care and service as well as people and patients!
We as a society accept mediocracy as the norm, rather than demanding better care. Paper work trumps patient care.

Great post and an eye-opening look into the realities of ER care. I thought about your story when I was listening to NPR this week and they had a feature on free-standing ERs (http://www.npr.org/blogs/health/2013/08/15/211411828/patients-can-pay-a-high-price-for-er-convenience). I would be interested in your thoughts about this potentially disruptive business model – “concierge service” ERs that aim to reduce/eliminate many of the problems you listed above (specifically, wait times). While they are more efficient and customer/patient-centric than your average ER, the downside is that they are expensive and therefore primarily sprouting in large cities where well-to-do patients can afford the steep prices of care.

Sorry for your experience. It hit home with me because I am currently being treated for breast cancer, and I reflect every day on the gap between what I know I should expect from the system, based on 30 years as a health care policy wonk, and what actually happens to me. I’m not always as good as I think I should be at closing the gap — I think it’s harder for me because I have no clinical credentials — and that makes a stressful experience even more so. It’s hard, too, because while some of the people you interacted with could have behaved better, we know that lots of the system problems aren’t really in the control of people at the front lines. My family seems perplexed about why I know about all these problems but can’t fix them (they consider me a superhero because I regularly win complex billing appeals to our health plans, but I am no superhero when it comes to the clinical side of things).
Anyway, it was comforting to me to know that you struggle with the health care system too!

Although it may not look like an extraordinary experience, it’s important because it’s your experience, your pain. We are not cattle; all of us who have been at a hospital with a lot of pain want to be treated as individuals, even if a thousand others have pain too. But since this situation is very common, I am going to prepare a card with all the information the hospital needs so I can hand it over to the clerk if need be. That might spare me a few minutes of agony.

People are the system. In an ER or anywhere else providers at all levels have the ability and the responsibility to respond. I can say that in all my years in the business, even as a consultant or executive in a suite, I have never walked past or avoided a patient in pain. Our systems are dysfunctional but only if the people within them allow them to be. Sounds tough…but not nearly as tough as being in pain and not attended to promptly.

I am an ER doc and I am sorry to hear about your story. I believe that I speak for all those who work in Emergency Medicine in saying that the care you received is something we are disappointed to see and something we strive to avoid. I would like to believe I am super human and never suffer from burn out, but all of us go through it from time to time. I agree it should be our mission to reduce this as much as possible. There is not segment of medicine or business that is immune to employees that get burnt out from time to time, but as the many of the replies point out, it seems to be an all too common theme in the Emergency Department (ED). The question should be, why does this happen more frequently in the ED that other segments of healthcare or business.

First off, let me point out where things likely went wrong with your visit (this is just postulating as I do not work at Falmouth, nor do I know their system, but I suspect it is similar to other ED’s). The triage nurse likely identified you are in pain and wanted to expedite your care, but did not choose the best manner to do so. If you would have had abnormal vital signs and needed immediate resuscitation (ie. you were exsanguinating or having a heart attack) you would have been brought to a resuscitation room where registration would have happened while you were being assessed and you would have received pain medicines within minutes. This is the triage system at work. You did not have a life threatening condition so this did not happen. That being said, there is an intermediate option where the triage nurse could have brought you back to a regular room and she could have notified the emergency physician and registration could happen at the bedside while the nurse and doctor were evaluating you. This occurs frequently in ED’s across the country in patients that are in significant amounts of pain. There seems to be a failure on the part of the triage nurse there to identify your need for pain medication. Unfortunately, when you were sent to radiology without receiving pain medicines, you are sort of lost to the world. Radiology is the no man’s land of the emergency department and unless you speak up, you go completely unnoticed. This is why we try to never send unstable patients to radiology without a nurse. I also medicate all my patients in pain before sending them to radiology. Radiology mostly only has techs working there that are very focused on doing xrays and not much else. That being said, the tech did notice you were in pain eventually, I am sorry it took them so long. They are mostly trained to get the xray done as fast as possible to get you back to your nurse where you can get more pain meds.

So there are obviously things that could have been done by a number of people to make your experience better, but it seems like the major failure was by the triage nurse and the registration person. So why were they burnt out and why did they not treat you with more expediency? Are they just bad people? Is it because their management does not give them training on patient care or service? Let me suggest an explanation. The Emergency Department has become the catch all for all societal problems. It used to be your local church, but now it is the ED. If you are desperate and have no place to go, or if you have minutes to live, or you are about to kill yourself, or your spouse is abusing you, where do you end up? This means on any given day the workers in the Emergency Department are met with death and despair, much of which we have no solution for. We see the same drug addicts and alcoholics cycle through our department day in and day out, despite our repeated efforts and pleading with them to go to detox and change their lives. I wish I could go talk to them and their family and say, look I cannot stop him from drinking but maybe if you help we can get him out of this, but often times their families have long abandoned them and whatever trauma their past lives dealt them, they have no other coping mechanism, so the providers in the ER become the community they rely on. We see parents who just lost their child to a car accident and a screaming and shaking in despair. We see patients in psychotic rage that attempt to punch, kick, and attack us. In fact the ER is one of worst places for workplace violence because psychotic and intoxicated patients can become agitated at any moment and attack you. And who is at the very, very front line of all this….the triage nurse and registration person.

I promise you that all the workers of the Emergency Department receive training in expediting care and improving patient satisfaction. We talk about Press Ganey scores (which is the evaluation of patient satisfaction, wait times and the like). In fact hospitals have been doing this for years and have been basing bonuses on these scores. However, I do not know how all the training in the world and all the bonuses is going to prevent burn out in a workplace environment as chaotic and unpredictable as the ED. I work with these people day in and day out and they are good people, but they have seen the darkest side of people and the darkest side of society and they have learned to protect themselves in ways that make them seem harsh. They also see pain everyday and often times pain they do their best to alleviate, but fail to alleviate despite their best efforts. In fact, we must inflict pain on people at times to improve their condition. Sometimes people become less sensitive to those in pain because of constantly being exposed to this. Add to this the constant stress of identifying patients that are feigning painful conditions in order to score some narcotic medications.

I can promise you this, though, if you are on death’s door, there is nobody who is going to work harder or faster to save your life, whether you are rich, poor, old, young, insured, uninsured, a murderer, or a saint. We will take anybody and work our tails off to save their life.

I also do not understand how you can compare this to any other segment of healthcare or any other business. When anything breaks down in healthcare or in our society, the results end up in the ER. Can you say that about any other segment of healthcare or any other business. If you want to avoid the chaos of this environment then I would recommend concierge medicine and freestanding ED’s, who will make sure you are insured long before they ever talk to you, but your wait time will be seconds, because only the well insured and rich can afford their care.

I hope you can now understand the forces that likely led to your experiences. I hope your experience is better the next time. However, if you want to help fix things, you cannot just point at the hospital and the ED, they are just a reflection of the societal problems they must deal with.

Having just spent 5 days in a hospital, beginning with the ED, with my daughter, I have so much I could write here….good people, yes. Bad systems, yes. Pain control? Oh, my… The one system that surprised me – was something called Rapid Response Team – it was an internal 911 a patient could activate if they felt they had exhausted all normal channels and things were not going well…in desperation we called and in 3 minutes a team representing HR and more were there….my daughter, all 23 years old of her and in awful pain – but also a grad student in conflict resolution (! – I just knew that education would come in handy) ran the meeting…she explained her concerns….from 3 days with no bed change of linens to poor pain control….and we learned that “pain control” is THE buzz word that gets attention. This system helped to improve things but 5 days later we were happy to leave and shaking our heads at a system which made me think of the kids’ song Three Blind Mice, where the mice all run in circles, unable to see….

” Even when I pleaded with her, she blew it off, reassuring me insurance information was important. Because that’s how we do business in healthcare. Making sure I was insured was much more important than making sure I was treated quickly.”

The system works against the patient. Hospitals need to know you are covered before they begin treating you because they don’t want to play a game of cat and mouse with you and with the insurance companies to ultimately get paid. Unfortunately that means you sit there in pain answered the same questions time and time again.

Ashish, sadly we health professionals have nearly all had experiences for ourselves or a loved one where things go badly or have a near miss.

I find your narrative account much more valuable–to inform other “consumers” and to help direct QI at Falmouth–than your CAHPS rating would have been. I am curious if anyone from Falmouth has seen this post or responded. That would be routine for a hotel on TripAdvisor, or for a UK hospital on NHS Choices or I Want Great Care.